For someone with a serious injury, it's not just a matter of getting in the door at the closest hospital, but getting in the door at the right hospital, says Dr. Arthur Kellermann, an emergency medicine specialist.
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When private hospitals transfer patients who don't have insurance to public hospitals, it's called "patient dumping." But a study from Stanford University published Wednesday suggests a twist: Hospitals, it seems, are less likely to transfer critically injured patients to trauma centers if the patients have health insurance.

This is actually suggesting that patients who have coverage for critical injuries may not be getting transferred as quickly as they should be.

Dr. Arthur Kellermann

Researchers at Stanford University looked at more than 4,500 trauma cases at 636 hospitals around the country to see what happened to critically injured patients who were brought to emergency rooms that weren't designated trauma centers. They found that non-trauma facilities were much more likely to admit patients who had insurance, whether it was private insurance or Medicaid coverage, than to transfer the patients to more skilled facilities.

"It's the opposite of the overly aggressive transfer of a poor patient," says Dr. Arthur Kellermann, dean of the medical school at Uniformed Services University and a trauma care specialist who was not involved in the study. "This is actually suggesting that patients who have coverage for critical injuries may not be getting transferred as quickly as they should be."

"That's the whole point of trauma centers," Kellermann says. "The expertise, the speed of response, the capacity to manage complex injuries is significantly better at major trauma centers. That's the whole reason certain hospitals are designated trauma centers." It's not just a matter of getting in the door at the closest hospital, he says, but getting in the door at the right hospital.

The study didn't assess how well the patients who were held at non-trauma centers fared. The researchers excluded patients over 65, and those who were discharged from the ER or who died. But Dr. Kit Delgado, the study's lead author and a former Stanford emergency medicine instructor, says critically injured patients "admitted to hospitals that are not trauma centers are at risk for worse outcomes."

It's unclear just who makes that decision to admit or transfer. Emergency physicians and nurses typically don't know whether their patients are insured or not. But Delgado, who is now an emergency care researcher at the University of Pennsylvania, says hospital administrators often weigh in on where uninsured patients end up, and that same dynamic, he says, could help explain why non-trauma centers are reluctant to give up paying customers.

"As an emergency physician," Delgado says, "you may get a tap on the shoulder by a case manager that suggests that you should consider transferring the patient out to a hospital where they can be taken care of and [where] they're willing to accept them without insurance."

The business of medicine too often dictates where patients are cared for, Kellermann says, and that includes whether a hospital admits patients or transfers them away. "That decision should not be influenced by economics one way or the other," he says. "It should be influenced only by what's in the best interest of patients."

It's not the first time researchers have found hospitals holding on to insured patients: Low-birth-weight babies do best at neonatal intensive care units that care for many such infants, but babies covered by insurance are less likely to be transferred.

Still, there could be other reasons why patients aren't transferred to hospitals that have more expertise: Patient preference may play a role.

Delgado is currently researching whether patients prefer to stay at their local community hospital rather than be moved to a trauma center — which might be part of a public hospital or located in an inner-city area. If patient choice is driving these decisions, Delgado says, hospitals need to do a better job of educating patients about where they'll get the best care.

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